Tuesday, January 25, 2011

Mirror neurons and the need for slow medicine

How long does it take for a silence to become uncomfortable? 5 seconds? 20 seconds? A minute? Students of education are taught to give a child roughly 20 seconds to answer a question posed to him. How long do teachers actually give? About 5 seconds, if that. Now sit there and count out 20 Mississippis and see what an astonishingly long time it seems. Why, what if a web page takes that long to load on your browser? This becomes a major technological tragedy for most of us. The point is that 20 seconds is a longer time than we appreciate.

Now, let's talk about empathy. Yes, empathy. This seeming non-sequitur has a solid connection. How do we like to experience empathy? Silent attentive listening is a great example of empathic engagement. When we talk with out friends about emotionally charged topics, we do not want them to respond with "yeah, yeah", and move on rapidly to the next topic, do we? So, empathy takes time and engagement. And when 20 seconds of silence seems like a long time, imagine it in a doctor's office, following a hard revelation or an emotional response by the patient. Can you? Are you counting the Mississippis?

Well, it is no wonder that doctors miss opportunities to express empathy to their patients. In a study from Canada, where oncologists were recorded during patient encounters, these doctors seized fewer than 1 in 4 opportunities to respond to their patients with empathy; the other 3 chances they squandered on discussing clinical information. And this is a pity, as is rightfully acknowledged by the investigator quoted in the article. His conjecture for why docs miss these opportunities to be empathic has to do with their apparently erroneous idea that it takes too much time, and his guidance is the following:

Showing empathy does not mean a doctor has to feel what his or her patient is feeling, Buckman says. Rather, it means acknowledging patients’ fears and other emotions.

“It is perfectly OK for the doctor to remain detached, but it is not OK to talk detached,” he says. “Acknowledging what a patient is feeling is not the same as feeling it yourself.”

Well, I have to respectfully disagree. Here is the meaning of the word "empathy" from the trusted Merriam-Webster dictionary:

2

: the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicitmanner; also : the capacity for this

And in fact, looking to brain science to guide us on how we are wired to accomplish this, we realize that by definition empathy implies non-detachment, and, in fact, involves feeling what the other is feeling. Empathy is mediated by the so-called mirror neurons, residing in the cingulate gyrus of the brain. The great neurobiologist VS Ramachandran thinks that the discovery of these neurons is to the study of human behavior what the discovery of DNA was to biology. It has been said that mirror neurons help "dissolve the 'self vs. other' barrier." It is these neurons that make us feel others' pain, literally and figuratively. So, putting ourselves in the other person's shoes and "feeling what the patient is feeling" is truly the sine qua non of empathy.

So, if the docs' intuition is correct, and empathy does mean non-detachment and time (after all 20 seconds represents 3% of a 10-minute appointment), how does the medical profession go about relishing and leveraging the other 3 opportunities for empathy instead of throwing them away? I agree with the point of the article that medical students should be taught empathic communication. At the same time, we learn by example, and if harried mentors continue to skirt these issues in the office because they are running two hours behind schedule already, the students will get the point loud and clear. The bigger issue is the incredible shrinking appointment, which is not only likely driving up healthcare costs and the frequency and intensity of testing, with its attendant adverse events, but is eroding the opportunity for a meaningful therapeutic relationship. After all, if the doctor herself provides a therapeutic benefit, is this not of utmost importance?

In short, this is another argument for slow medicine, an argument that should not be weakened by the detachment reasoning. My guess is that it is our biologic imperative as humans to exercise our mirror neurons avidly and often, and being forced to blunt their firing may be yet another path to demoralization. And is the medical profession not already demoralized enough?

Welcome and a disclaimer

Welcome to my blog, "Healthcare, etc."! In this blog I take the perspective of a researcher/policy wonk rather than an individual healthcare practitioner. Therefore, all opinions that I express and generalizations that I make about any issues will in no way be construed as medical advice for individual visitors / readers. All views expressed here are solely my own, and do not represent opinions of any organizations with which I am affiliated. I welcome all comments, but reserve the right not to publish paranoid or abusive rants or overt marketing pitches.

About Me

I am an independent physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. I am also a professor of Epidemiology at the University of Massachusetts, Amherst.
I am frequently invited to speak about evidence-based medicine, methods and healthcare-associated complications.
My posts have been syndicated on The Health Care Blog, KevinMD,The Healthcare Collective and other sites. They have also been cited in the New York Times. Occasionally you can also find me blogging on the British Medical Journal blog site http://www.doc2doc.bmj.com
If you would like to contact me about my research, blog posts or speaking, please e-mail me at Healthcareetcblog@gmail.com